FORT LEE FORM 190-3, JAN 2015

REQUEST FOR UNESCORTED INSTALLATION ACCESS TO FORT LEE

AUTHORITY: Title 5, USC 3331, 552, 552a; 10 USC 10204; Executive Orders (EO) 10450, 10865, and 12333. PRINCIPAL PURPOSE: The information requested is for the purpose of granting access to the Fort Lee Installation. ROUTINE USES: Basis for determination of qualifications and background information for eligibility for access to Fort Lee Installation. The Social Security Number (SSN), required for record accuracy, is requested pursuant to EO 9397. DISCLOSURE: Providing requested information, to include your SSN is voluntary. However, your access may not be granted if all requested information is not provided. Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off or send to a third-party. This document contains personal or privileged information and should be treated as "For Official Use Only (FOUO)".

DATA REQUIRED BY THE PRIVACY ACT OF 1974

PART I - APPLICANT INFORMATION

a. LAST NAME: b. FIRST NAME: c. MIDDLE INITIAL:

d. GRADE/RANK/STATUS: e. SOCIAL SECURITY NUMBER: f. DOB:

g. GENDER: Male Female h. E-MAIL ADDRESS:

i. PHONE NUMBER : j. EMPLOYER:

k. DRIVER'S LICENSE / ID # STATE: Exp Date. RACE:

PART II - VISITOR (N/A FOR CONTRACTORS/SUPPORT PERSONNEL) a. REQUESTED DATE(S) / TIME OF VISIT: FROM TO

GRADUATION MUSEUM VISIT FAMILY GOLF/BOWLING

a. MAKE: b. MODEL: c. COLOR: d. PLATE #:

PART III - VEHICLE

PART IV - CONTACT/SUPPORT PERSONNEL a. CONTRACT/GOVERNMENT BILL OF LADING #:

c. CONTRACT EXPIRES: d. COR/SUPERVISOR:

PART V - GOVERNMENT SPONSOR'S CERTIFICATIONI certify that the applicant meets the justification requirements as indicated in Part IV above for access privileges. Furthermore, I certify that the applicant requires an access control card as indicated above in order to perform assigned duties or conduct official business on Fort Lee.

a. COR/SUPERVISOR/PHONE NUMBER b. SUPERVISOR/SPONSOR SIGNATURE (Invalid if Incomplete) (Invalid if Incomplete)

SECTION BELOW IS FOR USE BY INSTALLATION ACCESS CONTROL OFFICE ONLYPART VI - ISSUING OFFICE

a. APPROVING OFFICIAL PRINTED NAME b. APPROVING OFFICIAL SIGNATURE DATE

a. APPROVED b. DISAPPROVED c. ACTION TAKEN (Specify below)

b. PURPOSE OF YOUR VISIT:

SPECIAL EVENT (Specify below):

b. GOVERNMENT ORGANIZATION/BUSINESS SUPPORTED:

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FORT LEE FORM 190-3, JAN 2015

FORT LEE INSTALLATION ACCESS CARD/PASS

1. I understand that I must give the Fort Lee Visitor Control Centers consent to an initial criminal history and periodic background screenings prior to and after the issuance of an installation access card/pass by completing Fort Lee Form 118. Failure to do so will result in the termination of the application process. I further understand that these background screenings will determine my eligibility for access and continued access during the term of my visit. a. I understand that my access may be revoked at anytime without reason or notice. b. I understand that I must properly care for my cards/pass to prevent damage, or unnecessary wear. c. I understand that it is prohibited to allow someone else to use my card/pass. d. I understand that my card/pass must be turned in to the Installation Access Office once it has expired or further use is not required. e. I understand that I must immediately report any lost, damaged or stolen card/pass to my sponsor and the military police. f. I understand that my card/pass must be controlled at all times. If you have and or know where your card/pass is,then it is considered secured! If your card/pass is lost or unrecoverable, please notify your sponsor immediately. 8. I have read and understand the instructions listed above.

ACKNOWLEDGEMENT STATEMENT

APPLICANT'S PRINTED NAME

APPLICANT'S SIGNATURE

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